Over 25 days, a $3 million inquiry has heard evidence from everyone involved in the bungled Melbourne hotel quarantine program.

It took hundreds of people from government agencies, hotel operators, private contractors and Victoria Police to pull off the monstrous operation, all while facing the ongoing threat of a global pandemic that was still in its infancy and gaining traction.

63 people were interviewed over the course of a few weeks including security guards, police, members of the ADF, public servants, Victorian government ministers, the Chief Health Officer, and of course Premier Daniel Andrews who rounded out witness submissions on Friday. 

WATCH: Premier Andrew's evidence.

And yet despite the many holes in this controversial program, and there are many holes, one person has taken the fall before the inquiry has even come to its conclusion. 

Victorian Health Minister Jenny Mika­kos has, as the ABC eloquently put it, been "publicly politically executed," as the government attempts to save face in an increasingly restless Victoria.

But Mika­kos didn't just resign on Saturday, she quit parliament altogether. And this one the day after Andrews told the hotel quarantine inquiry she was "accountable" for the scheme. 

To understand what happened to Mikakos, it's important to go back to the start. 

What went wrong with Victoria's hotel quarantine scheme?

The stakes for this inquiry are astronomically high, with the Victorian hotel quarantine scheme to blame for the second wave of coronavirus that's still making life miserable for an entire state. All while the rest of the country continues their stroll towards a new, relatively free, COVID normal. 

Outbreaks that began at Stamford Hotel and Rydges Hotel were pretty quickly blamed on infection control beaches, with the federal government immediately passing on any government blame to their state counterparts.

We have, after all, seen that the states and territories of Australia have been acting independently of not just eachother, but of federal direction as well. They've almost turned into mini countries of their own during this pandemic. 

Two Victorian hotel quarantine hotels are to blame for the second spike in coronavirus cases in the state. Image: Quinn Rooney/Getty.

In July Premier Daniel Andrews said that the spike in numbers in late May and early June could be the result of "an infection control breach in the hotel quarantine program."

Victoria made headlines around the world as accusations of security guards having sex with locked down travellers started to emerge.

According to security industry figures and quarantine-hotel insiders, hotel guards slept with guests, as well as shook hands and shared lifts with those in quarantine, which was a major breach of regulations. 

As the Herald Sun reported, there were also allegations that guards were caught sleeping on the job, wore the same personal protective equipment for up to eight hours at a time without changing it, and allowed families to go between rooms, playing games and mingling with others.

So a judicial inquiry was tasked with examining the claims, at a cost to the taxpayer of $3 million. 

It promised to find out how the hotel quarantine program was structured, what powers were exercised and by who, the timing and preperation behind it, how it was resourced, and government lines of supervision and accountability.

What evidence have we heard? 

Department of Health and Human Services (DHHS) says 99 percent of cases in the second wave in Victoria, can be traced back to outbreaks in the state's hotel quarantine program.

A family of four at Rydges, and two staff members at Stamford have been identified as the "patient zeros" in this mess. 

Here is some of the key evidence that's been heard as Justice Jennifer Coate AO tries to untangle the controversial scheme:

- The program was set up in 48 hours after the Federal Government directed the states to introduce quarantine schemes. 

- Claire Febey, a director with the Department of Jobs, Precincts and Regions (DJPR), told the inquiry she believed she was in charge of the program, but responsibility was then shifted to DHHS within a couple of days.

- The man put in charge of the day-to-day running of quarantine operations at several hotels, said he had not received any infection control training by DHHS before taking charge. Luke Ashford quit his job over concerns for his own safety.

- The program is estimated to reach $130.5 million in cost, $24.2 million over budget.

The Honourable Jennifer Coate AO has heard 25 days of evidence from 62 witnesses in the hotel quarantine inquiry. Image: James Ross/Getty.

- Complaints about guard's bad behaviour were escalated to DJPR, and were evident from "day dot."

- The Victoria police commander in charge of the program didn't think police were needed inside hotels because it wasn't a good use of their time, a decision backed by the then-Chief Commissioner of police Graham Ashton.

- The DJPR director put in charge of finding security personnel, said she did not realise subcontracting would occur — however the inquiry was shown her own handwritten notes, which appeared to suggest otherwise.

- One nurse who worked in the program told the inquiry there were "concerning conditions around access to fresh air and mental health support" while another said they were struggling with insufficient staff to guest ratios and sometimes lost track of guests because of poor record keeping.

- The Federal Government offered their state counterparts ADF assistance if Victoria wanted to reconsider its quarantine system, but the ministers involved don't even remember getting the email.

As this brief overview of some of the key points of discussion makes evident, there were many many cooks mixed up in this disaster, with senior counsel assisting the inquiry Tony Neal QC telling the inquiry: "From the very beginning it seems there were multiple and potentially overlapping areas of responsibilities between departments." 

The inquiry was also dominated by a lot of 'buck passing' as government, the public sector, and emergency services try to dodge blame, despite it being openly discussed that the whole program was run by multiple departments with a "shared responsibility."

This wasn't just one big mistake. It was lots of little mistakes that culminated in one big fat failure. 

So where does Jenny Mika­kos come in?

During her testimony to the inquiry on Thursday, Mikakos said she first learnt in late May that private security had been contracted to guard returned travellers, two months after the ill-fated program had been established.

But footage emerged on Friday of Ms Mikakos standing beside Jobs Minister Martin Pakula on March 29 as he told media that private security had been deployed to the hotels

The Age also published briefings that were given to Labor state MPs from April, outlining the decision. 

Embattled Health Minister Jenny Mikakos has denied she misled the inquiry into the Victorian government's botched hotel quarantine system after evidence emerged throwing her testimony into doubt. https://t.co/XE7Vu9MLIt

— The Age (@theage) September 25, 2020

Mikakos gave an additional statement to the inquiry on Friday afternoon, where she said she still had no personal memory of appearing in the press conference in March.

It appears the "gotcha" moment gave Premier Andrews, who appeared at the inquiry on Friday, the perfect scapegoat. 

After personally apologising for the failings in the scheme, Andrews threw his health minister under the bus.

When asked who was ultimately in charge of Operation Soteria (the quarantine program), Andrews said Jobs Minister Martin Pakula and Health Minister Jenny Mikakos had initial responsibility, but that after April 8, he considered Mikakos “accountable for the program.’’

Daniel Andrews appeared at the inquiry on Friday. Image: ABC.

"I then regarded Minister Mikakos as accountable for the program. The CCC was provided with regular reports by Minister Mikakos containing data relevant to Victoria’s response to the public health emergency, key insights from the data, as well as other updates, including in relation to the program," he told the inquiry.

It was blatant, unequivocal blame, for a scheme that multiple witnesses, including Mikakos herself, had already stressed was a "multi-agency operation with shared accountability."

The fallout.

On Saturday Mikakos resigned. 

She didn't call her boss, instead she texted him her decision. 

"I have never wanted to leave a job unfinished but in the light of the Premier's statement to the Board of Inquiry and the fact that there are elements in that that I strongly disagree with, I believe I cannot continue to serve in his cabinet," she wrote on Twitter.

"I have never shirked my responsibility for my department but it is not my responsibility alone. I look forward to the Board of Inquiry's final report. I am disappointed that my integrity has sought to be undermined," she added.

My media statement is attached. #springst pic.twitter.com/h0Quxyed2P

— Jenny Mikakos #StayHomeSaveLives (@JennyMikakos) September 25, 2020

Andrews thanked Mikakos for her "dedicated service," but said that while he had not asked for her resignation it was "the appropriate course of action for her to take."

"When you make a decision that you can't serve in the cabinet then you can't serve in the government you know to tender your resignation and that's exactly what happened," he told reporters. "I wish her well, and acknowledge her hard work and her passion and her commitment."

That's despite refusing to answer questions about why he believed it was appropriate for the state’s health minister to resign, and while saying he would wait until the findings of the hotel quarantine inquiry were handed down before commenting further.

As of this morning, Mikakos' Twitter profile already reads: "ex-Labor MP & Minister, now beginning a new chapter of life."

Her New South Wales counterpart is one of many questioning the premier's motives, writing: "Premier Andrews assertion that the Health Minister was responsible for the Quarantine system lacks logic. How could a Health Minister direct Police to be involved?"

Sorry to see Jenny Mikakos resign. She has worked tirelessly in this pandemic. Premier Andrews assertion that the Health Minister was responsible for the Quarantine system lacks logic. How could a Health Minister direct Police to be involved? @NSWHealth

— Brad Hazzard (@BradHazzard) September 26, 2020

But pressure has been mounting on the premier for weeks to provide answers to the questions that have left his state in the strictest lockdown in the world, struggling financially and emotionally in ways that will affect them for years to come. 

He needed an out, and Mikakos provided him the perfect one. She 'lied' to the inquiry, and whether that was on purpose or by accident, there were already calls for her to quit from the state opposition and Health Workers Union. 

Jenny Mikakos should wear some of the responsibility of course, but does she deserve it all?

Time will tell.

Chances are Mikakos won't be the only person who loses a job following the hotel quarantine bungle. 

Feature image: Quinn Rooney/Getty.